Diabetes In Primary Care Research Articles

Long-term effects of intensive multifactorial treatment on aortic stiffness and central hemodynamics after 13 years with screen-detected type 2 diabetes: the ADDITION-Denmark trial

BackgroundPeripheral and central hemodynamic indices are modifiable by lifestyle and medical intervention. We aimed to determine the long-term effect of intensive multifactorial treatment on peripheral and central hemodynamic indices among people with screen-detected diabetes.MethodsBetween 2001 and 2006, people with screen-detected type 2 diabetes were included in the Anglo-Danish-Dutch study of Intensive Treatment of Diabetes in Primary Care (ADDITION) trial (NCT00237549, ClinicalTrials.gov). In the Danish arm, participants were invited to a clinical examination in 2015–2016, 13 years after inclusion and 8 years after trial-end. Out of 586 eligible participants who attended the clinical examination, 411 had a valid examination of central and peripheral hemodynamic indices (242 received intensive treatment and 169 received routine care). Carotid-femoral pulse wave velocity (cfPWV), central blood pressure and augmentation index were assessed by applanation tonometry. We used mixed-effect models to examine the intervention effect adjusting for cluster randomization and heart rate.ResultsRandomization to intensive treatment during the trial-period was associated with a 0.58 m/s lower cfPWV (95% CI − 1.09 to − 0.06) at follow-up. Adjustment for blood pressure attenuated the association. Differences between intervention groups for central augmentation index were − 1.25% (95% CI: − 3.28 to 0.78), central pulse pressure − 1.74 mmHg (95% CI − 4.79 to 1.31), central systolic blood pressure − 3.06 mmHg (− 7.08 to 0.96), and central diastolic blood pressure − 1.70 mmHg (− 3.74 to 0.34).ConclusionsIntensive multifactorial treatment of screen-detected type 2 diabetes has a sustained positive effect on aortic stiffness measured by cfPWV. Although all estimates pointed in favor of intensive treatment, we observed no clear beneficial effect on other hemodynamic indices.

Glycated haemoglobin and fasting plasma glucose tests in the screening of outpatients for diabetes and abnormal glucose regulation in Uganda: A diagnostic accuracy study.

To understand the utility of glycated haemoglobin (HBA1C) in screening for diabetes and Abnormal Glucose Regulation (AGR) in primary care, we compared its performance to that of the fasting plasma glucose (FPG) test. This was a prospective diagnostic accuracy study conducted in eastern Uganda. Patients eligible for inclusion were consecutive adults, 30-75 years, receiving care at the outpatient department of a general hospital in eastern Uganda. We determined the sensitivity, specificity and optimum cut-off points for HBA1C and FPG tests using the oral glucose tolerance test (OGTT) as a clinical reference standard. A total of 1659 participants underwent FPG testing of whom 310 were also HBA1C and OGTT tested. A total of 113 tested positive for diabetes and 168 for AGR on the OGTT. At recommended cut-off points for diabetes, the HBA1C and FPG tests had comparable sensitivity [69.8% (95% CI 46.3-86.1) versus 62.6% (95% CI 41.5-79.8), respectively] and specificity [98.6% (95% CI 95.4-99.6) versus 99.4% (95% CI 98.9-99.7), respectively]. Similarly, the sensitivity of HBA1C and the FPG tests for Abnormal Glucose Regulation (AGR) at ADA cut-offs were comparable [58.9% (95% CI 46.7-70.2) vs 47.7% (95% CI 37.3-58.4), respectively]; however, the HBA1C test had lower specificity [70.7% (95% CI 65.1-75.8)] than the FPG test [93.5% (95% CI 88.6-96.4)]. At the optimum cut-offs points for diabetes [45.0 mmol/mol (6.3%) for HBA1C and 6.4 mmol/L (115.2 mg/dl) for FPG], HBA1C and FPG sensitivity [71.2% (95% CI 46.9-87.8) versus 72.7% (95% CI 49.5-87.8), respectively] and specificity [95.1% (95% CI91.8 97.2) versus 98.7% (95% CI 98.0 99.2), respectively] were comparable. Similarly, at the optimum cut-off points for AGR [42.0 mmol/mol (6.0%) for the HBA1C and 5.5 mmol/l (99.0 mg/dl) for the FPG test], HBA1C and FPG sensitivity [42.3% (95% CI 31.8-53.6) and 53.2 (95% CI 43.1-63.1), respectively] and specificity [89.1% (95% CI 84.1 92.7) and 92.7% (95% CI 91.0 94.1), respectively] were comparable. HBA1C is a viable alternative diabetes screening and confirmatory test to the FPG test; however, the utility of both tests in screening for prediabetes in this outpatient population is limited.

Severity of depressive but not anxiety symptoms impacts glucose metabolism among patients with type 2 diabetes in primary care.

BackgroundData from primary care regarding the prevalence of symptoms of depression and anxiety, and their effect on glycemic control among people with diabetes is lacking in Hungary. The recently introduced Patient Health Record (PHR) requires family doctors to screen for depressive symptoms.ObjectivesWe aimed to investigate the prevalence of depressive and anxiety symptoms among patients with type 2 diabetes in the general practice, and the relationship between these affective disorders and glycated hemoglobin (HbA1c) level.MethodsWe included 338 consecutive patients with type 2 diabetes from six primary care practices in this cross-sectional study. A self-administered questionnaire (patient history, anthropometric, socioeconomic, laboratory parameters), the Beck Depression Inventory (BDI) and the Hamilton Anxiety Scale (HAM-A) were used.ResultsThe mean age of the sample was 64.0 ± 11.5 (years ± SD), 61% of participants were female. The prevalence of depressive symptoms was 21%, mainly moderate/severe symptoms (13%). Anxiety symptoms were more common (35%). We found significant univariate association between the depressive symptoms and HbA1c (p = 0.001), suicide attempt (p < 0.001), anxiety (p < 0.001), micro- and macrovascular complication (p = 0.028 and p < 0.001), education (p = 0.001) and place of residence (p = 0.002). In multivariate analysis, however, only BDI score had significant (p = 0.03191) association with glycemic control.ConclusionAmong primary care patients with type 2 diabetes, the prevalence of depressive symptoms was less frequent than anxiety symptoms. More severe depressive symptoms were associated with worse glycemic control.

Diabetic retinopathy: long-term follow-up of Ecuadorian patients with type 2 diabetes in primary care

ObjectivesThe aim of this study is to evaluate the prevalence, associated factors, and time for diabetic retinopathy (DR) development in Ecuadorian patients with type 2 diabetes (DM2) followed for 10 years.MethodsA retrospective cohort study between 2007 and 2017 included 487 patients with DM2 who had at least one dilated fundus eye examination in Diabetes Center in a primary-health-care level followed up for ten years. Data was collected from clinical records. Sociodemographic and laboratory variables were analysed, determining their association (mean difference and bivariate logistic regression) with DR. Survival time was calculated through life tables and Kaplan-Meier analysis.ResultsThe prevalence of DR was 19.95% during the 10-year follow-up period. The median time for developing DR was 28.53 (95% CI: 26.89–27.05), showing that 50% of patients have the risk (HR: 4.57) to develop DR in the third decade of DM disease diagnosis. The significant risk factors for progression of DR were duration of DM2, high glycosylated hemoglobin level > 7% (HbA1c Expβ: 1.709, 95% CI: 1.00–2.89), systemic hypertension (HNT Expβ: 2.348 Expβ: 2.348 95% CI: 1.17–4.70%) 95% CI: 1.17–4.70%), low glomerular filtration rate (Expβ: 1.805, GFR, < 60 ml/min/sc1.73) (95% CI: 1.10–2.94) and albuminuria (Expβ: 2.48 Expβ: 2.48 95% CI: 1.49–4.13).ConclusionsHalf of the patients with DM2 treated in a primary level of care will develop DR in the third decade of the disease. There are risk factors related to development of DR, such as low GFR, high HbA1c, albuminuria and HTN. Low GFR, high HbA1c, albuminuria and high blood pressure are related with the presence of retinopathy in diabetes patients.

Quality of care and prescription patterns among patients with diabetic kidney disease-a large-scale cohort study from Taiwanese clinics.

AimsTo investigate the quality of care and prescription patterns of patients with diabetic kidney disease (DKD) receiving primary care at local clinics in Taiwan.MethodsA retrospective chart review was conducted in 43 primary care clinics in Taiwan. The patients’ baseline characteristics, laboratory tests, presence of complications and antidiabetic agents prescribed were analyzed.Results7,200 patients with type 2 diabetes mellitus were enrolled. Percentage of HbA1c, blood pressure (BP), and low density lipoprotein cholesterol (LDL-C) goals reached were 52.5% in HbA1c < 7%, 40.9% in BP < 130/80 mmHg and 79.7% in LDL-C < 2.59 mmol/L. 18.3% achieved all three ABC goals. However, patients with DKD had a lower rate of ABC goal attainment and higher rate of complications. Among DKD patients with eGFR ≥ 30 ml/min/1.73 m2 and on monotherapy, metformin was most frequently prescribed. As for dual therapy, the most common combinations were metformin with sulfonylurea and metformin with DPP-4 inhibitors.ConclusionsDiabetes patients in Taiwan receiving primary diabetes care at local clinics had generally satisfactory management performance. However, more aggressive HbA1c, BP, and LDL-C management among DKD patients should be emphasized. Contrary to current recommendations, SGLT-2 inhibitors and GLP-1 receptor agonists as frontline therapy were under-prescribed.

Prevention of suicidal behavior in diabetes: the role of primary care.

Studies in different countries suggest that the rates of suicide ideation, attempts and death are increased in patients with diabetes in comparison to the general population. Suicidal behavior in patients with diabetes is a significant but underappreciated problem. Elevated suicide risk in individuals with diabetes may be related to comorbid psychiatric disorders, particularly depression. Considerable evidence suggests a bidirectional relationship between diabetes and depression: individuals with diabetes are at elevated risk of developing depression and patients with depression are more likely to develop diabetes. Frequent comorbidity of diabetes and depression may be related to psychosocial and neurobiological factors. Other comorbid psychiatric conditions including anxiety and alcohol use disorders may also increase suicide risk in diabetes. Primary care physicians are likely the key to suicide prevention efforts in individuals with diabetes since they see almost half of individuals who die by suicide within 1 month of their suicide. The management of potentially suicidal patients with diabetes in primary care comprises six major components: management of diabetes and its complications, especially conditions associated with pain; diagnosis and treatment of comorbid psychiatric disorders; frequent assessment of suicide risk; restricting access to the means of suicide; specific treatments to reduce the predisposition to attempt suicide; and referral to psychiatric care. Suicide prevention in individuals with diabetes and other medical disorders is a difficult but critically important task.

Effectiveness and cost-effectiveness of an intervention to improve Initial Medication Adherence to treatments for cardiovascular diseases and diabetes in primary care: study protocol for a pragmatic cluster randomised controlled trial and economic model (the IMA-cRCT study)

BackgroundBetween 2 and 43% of patients who receive a new prescription in PC do not initiate their treatments. Non-initiation is associated with poorer clinical outcomes, more sick leave and higher costs to the healthcare system. Existing evidence suggests that shared decision-making positively impacts medication initiation. The IMA-cRCT assesses the effectiveness of the IMA intervention in improving adherence and clinical parameters compared to usual care in patients with a new treatment for cardiovascular disease and diabetes prescribed in PC, and its cost-effectiveness, through a cRCT and economic modelling.MethodsThe IMA intervention is a shared decision-making intervention based on the Theoretical Model of Non-initiation. A cRCT will be conducted in 24 PC teams in Catalonia (Spain), randomly assigned to the intervention group (1:1), and community pharmacies in the catchment areas of the intervention PC teams. Healthcare professionals in the intervention group will apply the intervention to all patients who receive a new prescription for cardiovascular disease or diabetes treatment (no other prescription from the same pharmacological group in the previous 6 months). All the study variables will be collected from real-world databases for the 12 months before and after receiving a new prescription. Effectiveness analyses will assess impact on initiation, secondary adherence, cardiovascular risk, clinical parameters and cardiovascular events. Cost-effectiveness analyses will be conducted as part of the cRCT from a healthcare and societal perspective in terms of extra cost per cardiovascular risk reduction and improved adherence; all analyses will be clustered. Economic models will be built to assess the long-term cost-effectiveness of the IMA intervention, in terms of extra cost for gains in QALY and life expectancy, using clinical trial data and data from previous studies.DiscussionThe IMA-cRCT represents an innovative approach to the design and evaluation of behavioural interventions that use the principles of complex interventions, pragmatic trials and implementation research. This study will provide evidence on the IMA intervention and on a new methodology for developing and evaluating complex interventions. The results of the study will be disseminated among stakeholders to facilitate its transferability to clinical practice.Trial registrationClinicalTrials.gov, NCT05026775. Registered 30th August 2021.

“Medicines is all that I can sometimes offer them”: challenges of providing primary diabetes care to persons with disabilities in Tamil Nadu

BackgroundPersons with disabilities have a higher risk for and poorer outcomes of type 2 diabetes. Primary health care providers face several challenges in providing primary diabetes care for them. This study was conducted to explore the challenges faced by primary health care providers in delivering primary diabetes services to persons with disabilities.MethodsWe performed a qualitative research study by conducting in-depth interviews among 13 primary health care providers including medical officers, staff nurses, community health workers and a physiotherapist. We adopted a descriptive qualitative research approach to data collection and analysis.ResultsPrimary health care providers often could only prescribe medications to persons with diabetes by proxy due to poor accessibility of the facilities. They felt that these patients also had poor compliance to treatment. They felt that the lack of standard guidelines for diet and exercise for persons with disabilities prevented them from giving them appropriate advice on the same and even if they did, persons with disabilities would find it very difficult to adopt dietary changes and physical activity as they were dependent on others for even their daily activities. They also felt that they couldn’t perform annual screening tests due to lack of accessibility to higher facilities. Some primary care providers did local innovations such as formation of peer support groups, utilization of resources of other programs to reach out to persons with disabilities and innovative physical activity techniques to care for persons with disabilities. They recommended that there is a need for specific guidelines for management of diabetes among persons with disabilities, treatment of chronic diseases among persons with disabilities must be incentivized and there must be intersectoral coordination between social welfare department and health department to achieve the goal of care for persons with disabilities.ConclusionsPrimary health care providers faced substantial challenges in providing primary diabetes care for persons with disabilities. There is a need for an effective public health policy to address these challenges.

National handbook for the prevention and control of diabetes in primary care (2022)

National handbook for the prevention and control of diabetes in primary care (2022) is made for the use in combination with the national guidelines for the prevention and control of diabetes in primary care (2022). It provides detailed information and supplementary for the contents involved in the guidelines.

Innovative mobile-health led participatory approach to comprehensive screening and treatment of diabetes (IMPACT diabetes): rationale, design, and baseline characteristics

BackgroundIndia has 66 million people with diabetes, of which a large proportion do not receive adequate care. The primary health centres can serve as platforms for early detection of diabetes and continuum of care.ObjectivesThis project evaluates a community-level technology-enabled system-level intervention based around the community health workers and primary-care physicians. We hypothesize that incorporation of a mobile clinical decision support system, with other process-level changes will improve identification and management of individuals with diabetes in primary care settings.MethodsA cluster-randomized trial in sixteen villages/peri-urban areas in Andhra Pradesh and Haryana will test the feasibility and preliminary effectiveness of this intervention. The effectiveness of the extended care intervention will be evaluated by the difference in HbA1c (glycosylated hemoglobin) measured at baseline and end-line between the two study arms. Qualitative interviews of physicians, ASHA, and community members will ascertain the intervention acceptability and feasibility.ResultsA total of 1785 adults (females: 53.2%; median age: 50 years) were screened. ASHAs achieved 100% completeness of data for anthropometric, blood-pressure, and blood-glucose measures. At baseline, 63% of the participants were overweight/obese, 27.8% had elevated blood pressure, 20.3% were at high-risk for cardiovascular disease (CVD), and 21.3% had elevated blood glucose. Half of the individuals with diabetes were newly diagnosed.ConclusionTechnology enabled transfer of simple clinical procedures from physicians to nonphysician health workers can support the provision of healthcare in under-served communities. Community health workers can successfully screen and refer patients with diabetes and/or CVD to physicians in primary healthcare system.

To promote the integration of prevention and treatment for the whole-course management of diabetes: interpretation of the national guideline for the prevention and control of diabetes in primary care (2022)

《国家基层糖尿病防治管理指南（2022）》在2018版基础上，基于卫生行政部门的管理要求和新近发布的相关领域研究证据，主要在糖尿病的管理要求、筛查、诊断、治疗、低血糖的识别和处理及慢性并发症检查等方面进行了更新。此外，首次增加了糖尿病中医药防治部分，为基层医务人员提供更全面的指导。.

Quality and Performance Measurement in Primary Diabetes Care: A Qualitative Study in Urban China.

Quality measurements in primary healthcare (PHC) have become an essential component for improving diabetes outcomes in many high-income countries. However, little is known about their implementation within the Chinese health-system context and how they are perceived by patients, physicians, and policy-makers. We examined stakeholders' perceptions of quality and performance measurements for primary diabetes care in Shanghai, China, and analyzed facilitators and barriers to implementation. In-depth interviews with 26 key stakeholders were conducted from 2018 to 2019. Participants were sampled from two hospitals, four community healthcare centers (CHCs), and four institutes involved in regulating CHCs. The Consolidated Framework for Implementation Research (CFIR) guided data analysis. Existing quality measurements were uniformly implemented via a top-down process, with daily monitoring of family doctors' work and pay-for-performance incentives. Barriers included excluding frontline clinicians from indicator planning, a lack of transparent reporting, and a rigid organizational culture with limited bottom-up feedback. Findings under the CFIR construct "organizational incentives" suggested that current pay-for-performance incentives function as a "double-edged sword," increasing family doctors' motivation to excel while creating pressures to "game the system" among some physicians. When considering the CFIR construct "reflecting and evaluating," policy-makers perceived the online evaluation application - which provides daily reports on family doctors' work - to be an essential tool for improving quality; however, this information was not visible to patients. Findings included under the "network and communication" construct showed that specialists support the work of family doctors by providing training and patient consultations in CHCs. The quality of healthcare could be considerably enhanced by involving patients and physicians in decisions on quality measurement. Strengthening hospital-community partnerships can improve the quality of primary care in hospital-centric systems. The case of Shanghai provides compelling policy lessons for other health systems faced with the challenge of improving PHC.

493-P: Medical Assistant Health Coaching for Type 2 Diabetes in Primary Care: A Pragmatic, Cluster-Randomized Controlled Trial

While good cardiometabolic control can reduce complications in type 2 diabetes (T2D) , many individuals do not achieve clinical targets. This real-world trial compared medical assistant health coaching (MAC) to usual care (UC) in improving outcomes among adults with T2D and ≥ 1 of the following in the past 90 days: HbA1c ≥ 8%, LDL ≥ 100 mg/dL, SBP ≥ 140 mm/Hg. This N=600 study was conducted from 2016-2021 at four cluster-randomized clinics within two diverse health systems in Southern CA: a large, private insurance-based system [n = 298, majority non-Hispanic White, English-speaking, mid/upper socioeconomic status (SES) ]; M age = 70.2 ± 12.6] and a Federally-Qualified Health Center (n = 302, majority Hispanic, Spanish-speaking, lower SES; M age = 56.9 ± 12.0) . MAC and UC received diabetes care as usual in primary care, with referral to diabetes education and/or specialists as indicated. MAC also received in-clinic and telephone-based health coaching for up to one year (1-14 sessions; M = 5.2 ± 2.8) . Baseline mean HbA1c = 8.8 ± 2.2%, LDL = 101.8 ± 44.8 mg/dL, and SBP = 137.9 ± 19.4 mm/Hg. From baseline to 12-months, the percentage of individuals meeting quality metrics increased in both groups: HbA1c &amp;lt; 8% (MAC: 74.8 to 79.9%; UC: 64.0 to 80.4%) , LDL &amp;lt; 100 mg/dL (MAC: 75.7 to 84.9%; UC: 72.6 to 82.4%) , SBP &amp;lt; 140 mm/Hg (MAC: 75.0 to 86.9%; UC: 80.2 to 86.4%) . When outcomes were analyzed continuously using multi-level modeling, both MAC and UC demonstrated statistically significant improvements on all clinical outcomes; however, the rate of improvement was largely equivalent across groups (time-by-group ps &amp;gt; .05) . Due to the pragmatic nature of this trial, there was marked variation (by design) in intervention duration and intensity across participants, and in clinical and sociodemographic characteristics of participants across health systems. Additional analyses examining under what conditions and/or for whom the MAC intervention may prove more/less effective will be presented. Disclosure A.L.Fortmann: Consultant; Ascensia Diabetes Care, Employee; Dexcom, Inc. A.Philis-tsimikas: Advisory Panel; Bayer AG, Novo Nordisk, Research Support; Lilly Diabetes, National Institute of Diabetes and Digestive and Kidney Diseases, Novo Nordisk, Viking Therapeutics. T.Clark: None. S.R.Spierling bagsic: None. H.Sandoval: None. K.L.Savin: None. S.Roesch: None. L.Gallo: None. Funding NIH/NIDDK 1R18DK104250

63-LB: Correlates of CGM Uptake among Adults with Type 2 Diabetes in Primary Care

Clinical trials indicate continuous glucose monitor (CGM) use in type 2 diabetes (T2D) can be beneficial across medication regimens and outpatient settings. CGM use in care for T2D is increasing rapidly, but little is known about predictors of CGM use in T2D. Adults (age 18-75) with T2D receiving primary care at an academic medical center enrolled in a RCT evaluating a self-management support intervention. The intervention did not address CGM use. At enrollment, patients completed an A1c test, self-reported demographic, clinical characteristics and individual (diabetes distress, diabetes self-efficacy, health literacy) , social (family/friend involvement, shared illness perception) , and behavioral (self-care behaviors) factors. The 15-month assessment queried CGM use in prior 12 months (current use/used and quit vs. no use) . We explored potential correlates of CGM use with unadjusted non-parametric tests of difference. Patients (N=109) completed 15-month assessments from July 2021 to March 2022. Mean age was 58±10 years; 57% female; 54% non-Hispanic white, 31% non-Hispanic black, 7% Hispanic; mean baseline A1c was 8.8%±1.8%. One-third (n=36) used CGM during the prior 15 months (including n=3 who quit) . CGM users were younger (median [IQR]: age 55 [47, 62] vs. 60 [53, 68], p=.031) , had higher baseline A1c (9.1% [8.1, 10.4] vs. 8.3% [7.5, 9.5], p=.048) and more were using insulin (69% vs. 36%, p=.002) as compared to non-users. CGM users also had higher baseline diabetes distress (45 [25, 55] vs. 30 [15, 50], p=.09) . CGM use was not related to gender, diabetes duration, race, ethnicity, health literacy, diabetes self-efficacy, family/friend involvement, perceiving diabetes as a shared illness, nor self-care behaviors. In a prospective study of adults with T2D from primary care clinics, younger age, insulin use, higher A1c and higher diabetes distress were associated with starting CGM. Two-thirds of CGM users were taking insulin. We did not find gender, race, ethnicity nor health literacy disparities in CGM use in our diverse sample. Disclosure L. S. Mayberry: Consultant; Abbott Diabetes, Cecelia Health. M. K. Roddy: None. S. S. Jaser: None. T. A. Elasy: None. Funding National Institutes of Health (R01DK119282)

507-P: Eighteen-Month Follow-Up of Peer Support for Diabetes Management in Shanghai Integration Model

In 9 Community Health Centers (CHCs) , peer leaders led neighborhood activities, co-led meetings on diabetes management, and followed up with individuals and families, all under the Shanghai Integration Model coordinating primary (CHCs) , hospital, and specialty diabetes care. Previously reported were significant changes in HbA1c, other clinical markers, and diabetes distress from baseline to the end of the active program at 12 months. Changes were pronounced among those exceeding criteria for heightened concern at baseline. Here we report extended impacts for all participants (1009) with baseline and 18-month data, controlling for all individual characteristics. Evaluation indicators and criteria for heightened concern were: HbA1c ≥ 8%, SBP ≥ 130 and DBP ≥ 80 mmHg, LDLc ≥ 2.6 mmol/L, BMI ≥ 26 kg/m2, PHQ8 ≥ - moderate depression, EQ5D quality of life and 4-item measure of diabetes distress - top tertiles. Reductions from baseline to 18 months were significant for HbA1c, SBP and DBP, and PHQ8 depression (ps: 0.00to 0.0088) . Among those exceeding criteria for heightened concern, reductions from baseline to 18-months were significant for all variables (ps ≤ 0.0001) including, e.g., HbA1c from 9.06% to 8.50% (SDs = 0.96, 1.55) . Research staff blinded to outcomes rated implementation of the peer leader program, yielding high- and low-implementation CHCs. For all participants, changes from baseline to 18 months were significantly greater in high- than low-implementation CHCs for HbA1c (p = 0.0246) and SBP (p &amp;lt; 0.0001) . Among those at heightened concern, reductions were greater in high- vs. low-implementation CHCs for HbA1c, SBP and DBP (ps: &amp;lt; 0.0to 0.0073) . Conclusion: Improvements in clinical and quality of life measures following peer leaders promoting diabetes self management as part of the Shanghai Integration Model were sustained over 18 months, especially for those with baseline measures indicating heightened concern and in high implementation CHCs. Disclosure Y.Liu: None. W.Jia: None. C.Cai: None. X.Wu: None. P.Y.Tang: None. M.M.Coufal: None. L.Shen: None. Y.Qian: None. S.Luu: None. E.B.Fisher: Advisory Panel; Lilly, Consultant; WellDoc, Research Support; Merck &amp; Co., Inc. Funding Shanghai Municipal Grants Award (GWIV-3.1) Shanghai Public Health Youth Award (GWV-10.2-YQ24) Shanghai Municipal Health Commission (201940141) Shanghai 6th People's Hospital (ynlc201812) The Merck FoundationSanofi China National Institute of Diabetes and Digestive and Kidney Diseases (P30 DK092926)

916-P: Evaluation of an Enhanced Primary Care Team Model to Improve Diabetes Care

Purpose: Primary care practices manage most patients with diabetes, and face significant operational, regulatory, and reimbursement pressures to improve care quality. The Enhanced Primary Care Diabetes (EPCD) model was developed to leverage the expertise of care team registered nurses and pharmacists to improve diabetes care. Methods: Utilizing a retrospective, interrupted time series design, we evaluated the EPCD model’s impact on a composite publicly reported quality measure of diabetes care (D5) , including indicators of glycemic control, blood pressure control, low-density lipoprotein, tobacco use, and aspirin use. We compared three groups of practices (32 total) that care for adults (age 18-75 years) with diabetes: staff clinician (physician and Advanced Practice Provider) practices with access to EPCD (5761 patients) , resident physician practices with access to EPCD (1887 patients) , and staff clinician practices without access EPCD (10,079 patients) . The primary outcome was a comparison of the pre-implementation trend (7 months) to the post-implementation trend (months) in the three groups for the percentage meeting the D5. Results: There was a positive difference in pre to post-implementation trends for patients meeting the D5 in the staff clinician practices in the EPCD group (Pre IRR 0.995, Post IRR 1.005; P= 0.01) . There was no difference in the trend for the trainee physician practices with access to EPCD (Pre IRR 0.999, Post IRR 1.011; P= 0.14) , and a significant negative trend in the staff clinician practices without access to EPCD (Pre IRR 1.001, Post IRR 0.994; P= 0.05) . Conclusion: The EPCD model significantly improved diabetes care quality. Further study of proactive, multidisciplinary chronic disease management led by care team nurses integrating clinical pharmacists is warranted. Disclosure J.Herges: None. J.Matulis: None. M.Kessler: None. L.L.Ruehmann: None. K.Mara: None. R.G.Mccoy: Consultant; Emmi. Funding National Institute of Diabetes and Digestive and Kidney Diseases (K23DK114497)

949-P: Pharmacist Interventions within a Collaborative Enhanced Primary Care Team Process Improves Diabetes Care

Purpose: An enhanced primary care diabetes model (EPCD) was implemented to provide proactive longitudinal care to adult patients with diabetes, grounded in close partnership between primary care providers (PCP) , registered nurses (RN) , and Medication Management Services (MMS) pharmacists. In this model, care team RNs could request pharmacist support through chart review for comprehensive diabetes management. The purpose of this study is to evaluate the impact of the MMS pharmacist in the EPCD model for patients with diabetes. Methods: All adults with diabetes paneled to a PCP in six primary care clinics in the Midwest U.S. were eligible for the EPCD model. We compared the change in diabetes care quality between patients who received pharmacist chart review and care recommendations to matched patients who did not. The index date was defined as the date of MMS pharmacist review after referral from the care team RN or date of RN review and no subsequent pharmacist consult. The primary outcome was the change in the proportion of patients meeting the composite of four diabetes treatment goals (D4) , including hemoglobin A1c control (HbA1c less than 8%) , blood pressure control (less than 140/90 mmHg) , aspirin use if indicated, and statin use if indicated at six months from the index date. Secondary outcomes were each of the four indicators individually. Results: The proportion of patients meeting the D4 after 6 months increased with pharmacist chart reviews (N=85) compared to matched patients with no review (N=170) (27% vs. 7%, p&amp;lt;0.001) . The change in patients meeting treatment goals of HbA1c (12.9% vs. 4.1%, p=0.020) , blood pressure (9.4% vs. 2.4%, p=0.023) , aspirin use (10.6% vs. 2.9%, p=0.018) , and statin use (17.6% vs. -1.2%, p&amp;lt;0.001) were increased with a pharmacist review. Conclusions: Pharmacist engagement in the EPCD model improved diabetes care quality. This supports the inclusion and utilization of pharmacists in multidisciplinary efforts to improve diabetes care. Disclosure D.Hess: None. R.G.Mccoy: Consultant; Emmi. J.Matulis: None. M.Kessler: None. K.Mara: None. J.Herges: None.

Tackling diabetes as a team: co-designing healthcare interventions to engage couples living with type 1 diabetes

AimsCouples living with Type 1 diabetes: co-designing interventions to support them.MethodsThis is a qualitative study comprising two phases. Phase I represents the exploratory phase, consisting of semi-structured interviews with persons with Type 1 diabetes (N = 16) and partners (N = 6). In the second phase, co-design principles guided workshops with healthcare professionals, persons with Type 1 diabetes, and partners (N = 7) to facilitate discussion of the key themes identified and solutions to engage couples living with Type 1 diabetes in diabetes care.ResultThe key themes identified from phase I as priorities to target in future interventions were: (i) Emotional impact of diabetes and (ii) Partners’ involvement. Priority (i) captures the impact the emotional burden of diabetes management produces within couples’ relationship. Priority (ii) captures the request from partners to be more involved in diabetes management. Characteristics of the interventions suggested during the co-design phase II focused on engaging patients and partners via a counseling point in healthcare settings and tailored help for couples’ psychological support needs.ConclusionsCouples value pro-active intervention and support from their diabetes team or primary care for both the partners to live well with Type 1 diabetes.

The effect of COVID-19 on routine diabetes care and mortality in people with diabetes

The effect of COVID-19 on routine diabetes care and mortality in people with diabetes

Type 2 Diabetes mellitus treatment intensification and deintensification in primary care: a retrospective cohort study

AbstractThe prevalence of type 2 diabetes is increasing worldwide, presenting a considerable clinical and public health burden. Existing evidence demonstrates that optimisation of diabetes treatment regimens can reduce the risk of morbidity and disability. This retrospective observational cohort study aimed to identify factors associated with treatment intensification and deintensification in people with type 2 diabetes and evaluate effects of the treatment approaches on clinical outcomes. The cohort included 183 patients enrolled in a primary care Diabetes Medication Therapy Adherence Clinic program in Malaysia between 1 January 2016 and 31 March 2020. Multivariable logistic regression analyses were conducted to determine the clinical or socio‐demographic characteristics associated with treatment intensification or deintensification. A total of 175 patients were included in the final analysis. Eighty‐seven patients (49.7%) had their medicine regimens changed, of which 27.4% (n = 48) of patients had their medicines intensified, 8.6% (n = 15) of patients had their medicines deintensified, and 13.7% (n = 24) of patients had their medicines intensified and deintensified. In multivariable analyses, treatment intensification was associated with higher knowledge of medicine scores. No factors were significantly associated with treatment deintensification. Patients who had their medicines intensified and deintensified had a lower post follow‐up target glycated haemoglobin level, fasting plasma glucose, and random blood glucose values compared to the baseline. The study found variability in the frequency of intensification or deintensification of diabetes medicine regimens and the factors associated with it. Treatment deintensification was relatively uncommon. To prevent overtreatment, further investigations are warranted to understand the impact of treatment deintensification on patients who were already receiving intensive therapy for type 2 diabetes.